Intake Form 

Please print this page and bring it to your first session along with a signed copy of the policies on the previous page. If you have a medical referral you can text a photo to me or bring it along with your copies of the policies and Client Intake forms.

                                                                  

Client Consent and Questionnaire                         

 

Name_______________________________________________________________________________

 

Address _____________________________________________________________________________

             

 ____________________________________________________________________________________                                 

 

____________________________________________________________________________________

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Best phone number____________________________________

 

 

Best email ___________________________________________

 

Name of emergency contact: ______________________________________

 

Their phone ___________________________ email ________________

 

Relationship:  ____________________________________________

 

 Do they live with you? Yes_______  NO__________

  

 

Briefly describe the reason for your visit.____________________________________________

 

____________________________________________________________________________

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____________________________________________________________________________

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How long have you had this discomfort or situation ______________

 

 

Do you have a doctor or chiropractor’s referral for medical massage?     yes______    no______

 

How did you find me?     _______________________________________

 

Do you have any ongoing health issues, such as diabetes, heart disease, depression for which you take medication?

 

Please list:__________________________________________________________________________   

 

 

Covid-19 Related Questions

 

1.Have you been asked to self-isolate or quarantine by a doctor or a local public health official in the last 14 days?

 

2. Have you been tested for COVID-19?   NA______  If so, when?    _____ /____/____

 

a. What was the result?      Positive_____   Negative______

 

3. In the last 14 days:

 

  1. Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath, or other respiratory problems, new, or strange symptoms)?   

  2. Yes______   No______

       If yes, please describe___________________________________________________

 

4. I'm fully vaccinated. Are you fully vaccinated against COVID-19?   Yes_______  No_______

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   1. If not, are you partially vaccinated?  Yes______  No______

    2. If not, do you plan to do so?  Yes_____    No______

 

5. Have you had close contact with or cared for someone diagnosed with COVID-19, or someone exhibiting cold or flu-like symptoms?  Yes______   No______

 

6. Have you been tested for COVID-19?

      a. if so, when  ______/______/_____

      b. What was the result?    positive _______  negative_____   

 

7. Have you been somewhere with a high infection rate in the last 2 weeks?   Yes_______   No______

 

8. Have you been to any unmasked gatherings, such as political rallies, beaches, schools, or parties in the last 14 days?      Yes_____   No_____

 

9. I have seen the policies under "Other" on this site and I agree to abide by them.  Yes_______    No_______  

 

 

For everyone’s well-being:

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I acknowledge that while precautions are taken for my safety, any bodywork, or in-person meeting carries inherent risks. By coming to an appointment I am accepting these risks.     Yes_______    No_______

 

Should any answers to the previous questions change, I agree to inform Ms. Peltier immediately.   Yes____  No___

 

Furthermore, if I have a temperature above 100.2°F on the day of the appointment, or have developed cold or flu-like symptoms since scheduling the appointment, I agree to inform Ms. Peltier and postpone my session? 

Yes_______   No _______

 

I also agree that should I fail to inform Ms. Peltier of any changes to my health prior to my appointment, or I have a temperature of 100 degrees or more upon arrival, she has the right to refuse service.    

Yes________   No__________

 

I agree to these conditions and affirm the truth of my statements:  Yes______

 

Signature:  __________________________________________________________  

 

Date___________   

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